2 This study Evaluated hospital care provision for people with dementia living in two wards in a hospital in Malta. Focused on: Environmental design Psychosocial care delivery Staff understandings and practice of personcentred care

7 Comparison of key design features T1 and T2: improved Visual access improved signposting using pictures of local landmarks and religious objects Stimulus enhancement signs on toilet, shower and bathrooms. Privacy slight improvement in ensuring privacy during intimate care Community provision of quiet seating area in one ward, but at end of a long corridor and unused Community access verandas more attractive to sit in.

8 Comparison of key design features T1 and T2: unchanged Stimulus enhancement excellent natural lighting from large veranda windows Familiarity some personal items on bedside lockers and some cultural objects in wards Safety low scores reflect hospital design of wards Ward size larger than recommended for optimal experience; 28 and 31 patients respectively Stimulus reduction very loud buzzers and door entry bell Walking and access outside poor access to outside spaces Community access few areas for visitors to spend time with their relative/friend other than beside bed or in television room Domestic activities no opportunity or space to engage in domestic or meaningful activity.

11 Comparison of DCM between T1 and T2: improved Slight improvement in attention to patient dignity In one ward more positive interactions between staff and residents Improved awareness of patient experience ensuring television programmes are not potentially distressing.

12 Comparison of DCM between T1 and T2: unchanged Staff were kind and wanted to do a good job Despite high staffing levels, tasks rushed and patients disempowered or ignored Insufficient positive interaction between staff and patients Lack of insight into patient experience Poor continence promotion Inappropriate use of restraint.

13 Person Centred Care Assessment Tool agree/strongly agree We often discuss how to give person-centred care. 89% 89% We have formal team meetings to discuss residents care. 89% 97% The life history of the residents is formally used in the care plans we use. 75% 75% The quality of the interaction between staff and residents is more important than getting the tasks done. 45% 51% We are free to alter work routines based on residents preferences. 54% 57% Residents are offered the opportunity to be involved in individualised everyday activities. 72% 79% Assessment of residents needs is undertaken on a daily basis. 77% 79% I simply do not have the time to provide person-centred care. 23% 18% The environment feels chaotic. 10% 18% We have to get the work done before we can worry about a homelike environment. 43% 56% This organisation prevents me from providing person-centred care. 29% 43% It is hard for residents in this facility to find their way around. 14% 15% Residents are able to access outside space as they wish. 26% 28%

14 Person-centred Climate Questionnaire, staff version - agreement A place where I feel welcome. 94% 70% A place where I feel acknowledged as a person. 91% 67% A place where I feel I can be myself. 82% 61% A place where the patients are in safe hands. 100% 94% A place where the staff use a language that the patients can understand. 100% 79% A place which feels homely even though it is in an institution. 86% 81% A place where there is something nice to look at. 91% 74% A place where it is quiet and peaceful. 73% 64% A place where it is possible to get unpleasant thoughts out of your head. 66% 59% A place which is neat and clean. 97% 85% A place where it is easy for the patients to keep in contact with their loved ones. 100% 84% A place where it is easy for the patients to receive visitors. 97% 97% A place where it is easy for the patients to talk to the staff. 91% 91% A place where the patients have someone to talk to if they so wish. 91% 90%

15 PCAT: congruence between staff views and observational data Staff reported discussing how to give person-centred care, suggesting a theory-based platform for practice. However, DCM data indicates there is much more work to be done. No change in recognition of the importance of life history in care plans, however DCM data indicated scant usage of this in practice. A slightly increased recognition of offering patients the opportunity to be involved in individualised everyday activities, however DCM data reveal the narrowness of activities patients engaged in. An increase in the view that the organisation prevents provision of person-centred care, however DCM data indicate high staffing levels.

16 PCQ-S: congruence between staff views and observational data Staff felt their practice was person-centred but DCM data indicated there is work to be done. Changing perception of the importance of communicating in a language patients can understand = decline in confidence in communication abilities, fewer English or Maltese speaking staff? Supported by DCM data. Changing perceptions of the environment suggests more awareness of the importance of making the hospital wards more dementia-friendly; EAT data supports slight improvements but PCAT data contradictory.

17 Concluding comments This study demonstrates the utility of taking a 3- pronged approach to assessing quality of dementia care and experience of living in hospital wards. Some increase in awareness of the principles of a person-centred approach and dementia friendly design. Applying this knowledge in practice takes commitment and effort from management and staff teams. Some changes to improve practice were easily implementable, others will take longer and will involve more sustained work.

18 Next steps Recommendations to support continuing improvements in care for people with dementia in hospital 1. Training and mentoring of staff of all levels 2. Ensure patients dignity and respect their rights 3. Ensure privacy when carrying out personal care 4. Formal team meetings and informal discussions to promote and recognise good practice 5. Recognise and respond to differing needs 6. Make the most of opportunities that present themselves 7. Promote meaningful interaction between staff and patients and between patients themselves 8. Promote a variety of activities for patients 9. Promote mobility 10. Ensure access to outside space 11. Staff to discuss and consider use of space to promote patient well-being and good practice 12. Promote continence 13. Provide objects that are interesting/stimulating 14. Involve families in ward life and decisions 15. Involve patients in ward life

19 Acknowledgements Thank you to the staff of both wards for welcoming us and helping us with our fieldwork and thank you to the patients for giving us an insight into their experiences. Ethical approvals for the evaluation were granted by the Hospital Research Committee, University of Malta Research Ethics Committee and the School of Applied Social Science Ethics Committee, University of Stirling.

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